When Pat Deaken’s back pain sets in—the result of degenerative disk disease and a severe curvature in her spine—she no longer immediately reaches for her pain meds. Instead, she inhales deeply and exhales slowly, taking notice of where her pain is. It’s usually in her lower back. She makes her pain the main point of her concentration as if she’s zooming into it. “The mindfulness makes me stop and think about where and how my pain is,” said Pat. “The breathing relaxes me and reduces my anxiety so I don’t mind the pain as much.”
Pat still takes opioid medication for her chronic pain condition, but has decreased the amount she takes significantly since learning a variety of mindfulness techniques in the Mindfulness-Oriented Recovery Enhancement (MORE) program, pioneered by University of Utah professor, Eric Garland, Ph.D., Aimed at decreasing patients’ use (and misuse) of prescription drugs, the eight-week program teaches mindfulness techniques to ease pain and craving, while using savoring practices to shift participants’ awareness to the emotions that arise in response to a pleasant experience.
Pain and the Opioid Epidemic
Chronic pain—or pain that exists every day for at least three months—is a serious problem for Americans, afflicting over 25 million adults, or 11.2% of the population. But the pain, itself, is no longer the only problem. Opioids, such as oxycodone (OxyContin) and hydrocodone (Vicodin), are used frequently as an antidote to chronic
While pain levels have reportedly remained the same over the past two decades, the numbers of opioid medication prescriptions—sold to pharmacies, hospitals, and doctors’ offices—has quadrupled. Doctors prescribe opioids medications, a class of drugs that can effectively regulate pain, particularly following injury or surgery. But the risks of falling victim are high, making them the root of a catastrophic epidemic. The probability of long-term opioid use rises most sharply in the first days of therapy, especially after five days of taking the medication. And that number increases to about 13 percent for patients who first took the drugs for eight days or more. It only takes an initial 10-day opioid prescription for one in five patients to become a long-term user.
It only takes an initial 10-day opioid prescription for one in five patients to become a long-term user.
“In the current epidemic we are facing, most people begin with a legitimate prescription for pain relief and take opioids as prescribed by their physicians,” said Garland. “But there’s a subset of patients who start taking opioids to simply control pain and begin to slip down this cycle towards greater dependence on the drug and migrate into misuse—these are the folks at heightened risk.”
The standard treatment, once a diagnosis of opioid addiction is made (DSM-5 provides diagnostic criteria for the term “opioid use disorder”), involves the use of methadone and buprenorphine, part of a class of extended-release and long-acting opioids that are approved for the treatment of opioid addiction. Opioid addicts can safely take these medications for months or years. But this type of treatment is not without complications and controversy, and the overwhelming surge of addiction rates is prompting a much-needed examination of alternative treatments to curb the rate of misuse.
The Neuroscience of Opioid Addiction
Enter mindfulness, which Garland has been researching as a therapeutic tool to target chronic pain and opioid use simultaneously. The results of a 2014 study led by Garland and published in the Journal of Consulting and Clinical Psychology showed that Mindfulness-Oriented Recovery Enhancement significantly decreased pain while simultaneously reducing opioid misuse by 63%. A follow-up study published by Garland and colleagues in the Journal of Behavioral Medicine, showed that for a sample of chronic pain patients who had been misusing opioids and who subsequently underwent the mindfulness intervention, the more their brains were activated by natural, healthy rewards and positive experiences—such as a beautiful sunset, an affectionate animal, and delicious foods—the less they craved opioids. These results, along with additional studies showing MORE’s potential impact on heart-rate variability, have initiated a quest for more research on the effects of mindfulness on chronic pain and opioid addiction, bringing Garland $23 million in grants, awarded by the NIH, the Department of Defense (DOD), and the Patient-Centered Outcomes Research Institute (PCORI).
“The findings are scientifically important because one of the major theories about how and why addiction occurs asserts that over time, drug abusers become hypersensitive to drug-related cues, such as driving past a pharmacy or seeing a pill bottle, and dulled to the pleasure derived from natural, healthy rewards, like enjoying the beauty of nature, social connections and positive life experiences,” explained Garland. “So as addicts lose the ability to feel joy from spending time with a friend or playing with a pet, for example, they are pushed to take higher and higher doses of the drug to obtain comfort and relief.”
Garland’s research suggests that this process can be reversed. “We can teach people to use mindfulness to appreciate and enjoy life more, and by doing that, they may feel less of a need for addictive drugs,” he says. “We need a treatment that not only targets addictive behavior but also the pain that drove the person to start taking opioids in the first place.”
“Over time, drug abusers become hypersensitive to drug-related cues, such as driving past a pharmacy or seeing a pill
bottle,and dulled to the pleasure derived from natural, healthy rewards, like enjoying the beauty of nature, social connections, and positive life experiences.” —Eric Garland, Ph.D.
Findings indicate that the MORE program reduces pain intensity itself by teaching people to shift from a more emotional way of processing pain to a sensory way of processing pain. Rather than focusing on pain as an awful, emotionally agonizing experience of suffering, the MORE patients are taught mindfulness skills to deconstruct the pain experience into its sensory components—such as sensations of heat, tingling, or tightness, as well as to notice non-painful or even pleasing sensations. “Thus, ‘pain’ is just a word or label we attribute to a cluster of sensations that may be innocuous or harmless in and of themselves,” said Garland.
Garland sees MORE therapy as a promising treatment for addiction, and the next step is to confirm its efficacy in full-scale clinical trials and to understand for whom mindfulness-based therapies work best. What is novel about the MORE intervention, he explained, is that it’s based on the neuroscience of addiction and designed to target specific mechanisms underlying the problem of addictive behavior and chronic pain. MORE restructures reward processing, from valuation of drug reward to valuation of natural rewards, and also uses mindfulness practices to strengthen self-regulation of automatic drug-use habits,” said Garland. “In our new studies, we will be able to measure how MORE changes the brain’s ability to regulate pain and respond to natural rewards, as well as deepen our understanding of exactly how these changes in neural mechanisms happen.”
What Mindfulness for Opioid Addiction Looks Like
The MORE program is made up of three mindfulness-based components—mindfulness, reappraisal and savoring—aimed at training the participants’ mind to learn how to focus their attention on the present moment, allowing them to bring awareness to automatic habits and more fully engage in their present moment experience.
- Mindfulness, such as mindful breathing and body scans that bring awareness to sensations of the body lay the groundwork for learning focused concentration as a way to gain an objective, non-judgmental stance toward their pain. Mindful eating introduces a routine that many of us do on autopilot, and is an example where slowing down and being mindful can enhance an experience. For learning about the mindfulness of urges, Brandon Yabko, Ph.D., a psychologist who leads MORE groups of Veterans in Garland’s lab, said that they use chocolate—asking participants to examine the urge to eat it—as a tool to practice being mindful of urges. Participants are then asked to imagine that the chocolate is their pain pill, and finally given the choice of eating or throwing out their “pill.”
- Reappraisal, where a client learns to reframe the meaning of a stressful or habitual action, such as fighting pain, in order to see that event with greater flexibility, even as purposeful and growth promoting. “This is a mindful twist on the ABC’s of cognitive therapy, where we ask participants to examine an Activating event, Beliefs about the event, and Consequences, or emotions, related to the specific event,” said Yabko. Followed by a mindful breathing practice, the participants are then asked if they could look at their beliefs from a different perspective. “Most of the time, they begin to see that there are other ways to look at this event and some even hold off on using their pain medication for a few minutes, hours, or maybe longer.”
- Savoring pleasant events, one of the highlights of this treatment, according to Yabko, teaches participants how to mindfully focus their attention on a positive experience, as a way to concentrate on and expand positive feelings. During a meditation, for example, MORE participants were instructed to focus their awareness on the colors, scents and textures of fresh flowers and to notice the joy that arises from that experience. They are learning to see how the mind and body respond, and to notice the emotions and physical sensations that result from being aware of natural beauty.
Change the Struggle, Not the Pain
Emily Johansson, 44, takes opioids to help with her rheumatoid arthritis and myofascial pain syndrome, and noticed a couple of years ago that she was also using the meds for anxiety. Since learning mindfulness, Johansson said she’s emerged from a dark place. “Learning how to not judge my thoughts and notice them as a third party, watching them float away on a cloud has made a huge difference,” she explained. Her daily practice, learned in the MORE program, has given her the tools to pause and consider an alternative before popping a pain med. “When it’s time to take a pill, I’ll check in first to see how I’m feeling and ask myself, ‘Would a body scan be helpful? Or a recorded mindfulness meditation? Can I wait a while?’” she added.
Using the breath and opening to an awareness of her body sensations helps Johansson shift into a more grounded, objective frame of mind, from where she can explore her pain. Sometimes she’ll opt for a walk to the park, or play with the neighbor’s dog, using the practice of training her attention on the present moment to notice the beauty, rather than focus, or hyperfocus, on her pain. During the eight-week program, Johansson learned the benefits of savoring her present moment experience, and how to “drink in” the sights, sounds and smells and let them flow through her body. “When I am feeding the baby ducks and geese, I don’t think about the pain,” she said.
With mindfulness-based therapy, chronic pain patients are learning to change their relationship to their pain.
With mindfulness-based therapy, chronic pain patients are learning to change their relationship to their pain. It’s a path they can take to go from a non-accepting, combative, judgmental perspective, to one of acceptance, openness and curiosity.
Yabko shares with his MORE groups his own personal experience with chronic pain and mindfulness. He tells them how he began practicing mindfulness 10 years ago, and that it didn’t reduce the chronic pain he felt in his back, but it reduced his struggle with the pain. “When people get wrapped up in fighting their pain, they end up creating such a deep tension within themselves that they are causing suffering,” said Dr. Yabko. “Opioid misuse comes from that suffering component.”
Judson Brewer, MD, Ph.D., a psychiatrist, addiction expert, and Director of Research and Innovation at the Mindfulness Center at the School of Medicine at Brown University, agrees that when chronic pain patients resist pain, that increases the level of suffering, and when they stop resisting, suffering decreases. “From a preventive angle, someone with chronic pain can learn to be with and work with pain on a sensation level, noting that this is heat, tension, burning, vibration,” said Dr. Brewer. “When they have pain, they also see that it comes and goes, it changes: pain is not the same from moment to moment.”
According to Brewer, cravings for drugs have a lot of similarities to the impact of pain. “They drive us to do things, give us feelings of restlessness, tension, tightness—sensations people can identify with when they feel chronic pain,” he explained. “There are a lot of overlaps, especially that restless, driving quality that says do something to make this go away, and the do something is opioids.”
When chronic pain patients resist pain, that increases the level of suffering, and when they stop resisting, suffering decreases.
Don Deaken, Pat’s husband, worked for 42 years as an oil-field machinist, a job that required heavy lifting. Now a diabetic with neuropathy from his knees down, Deaken has had four back surgeries and continues to live with constant back pain. He began taking opioids in 1999, and over time his dosage increased to 15 milligrams of oxycodone, six times a day. “I was pretty doped up most of the time,” said Deaken. But when he began having difficulty breathing at night, his doctor suggested cutting back on the opioids and sent him to the University of Utah’s Center on Mindfulness and Integrative Health Intervention Development (C-MIND), where he began the MORE training program.
Since learning mindfulness in the spring of 2016, Deaken has cut back his pain meds significantly, reducing them from 15 to 5 milligrams, and from six to four times a day. “I was always taking pills just to get rid of the pain, and now I take them to keep it under control,” Deaken said. “The pain never goes away, but mindfulness has taught me how to focus on the pain rather than ignore it, so when I breathe into the spot where I feel it, I relax in a way that helps the pain fade.”
So can these mindfulness-based therapies prevent chronic pain sufferers from reaching straight for their powerfully addictive pain meds?
It remains to be seen, but looks encouraging. “After someone practices mindfulness for a period of time, their cravings usually go down, because they are like emotions that come and go, and they don’t last forever and the patients begin to see that,” said Yabko.
Mindfulness exercises are the prescription Emily Johansson wishes every chronic pain sufferer could have. “Pain wants to control your brain and get your full attention until you give it a pain med,” she said. Johansson has learned to zoom in on her pain, accept it and let it go, and using mindfulness has helped her feel hopeful. “I went out to my car after it snowed one day and I stood there, watching the snowflakes,” she said. “They had spikes on them and are such a simple, cool part of nature, something I ‘d never noticed before. When I slow down, I can see there are things going on in my life that can be enjoyable.”